Palliation for the frail older adult and what meaningful longevity could be
Authors: William E Rosa, Stephen Connor, Betty R Ferrell, Terry Fulmer, Jasmine L Travers, Lukas Radbruch
Journal: The Lancet Healthy Longevity (2023)

Although frailty can be accompanied by increased health-related suffering, fully integrated generalist and specialist palliative care are often forgotten necessities for frail older people with physical and cognitive decline. Take Anne (pseudonym) for instance: a 96-year-old widow with lumbar disc degeneration and worsening dementia, now wheelchair bound and needing assistance for all activities of daily living. The loss of independent mobility—which Anne deeply valued—has caused depression. Anne's primary team does not recommend physical therapy because she has shared concerns about travelling to health appointments. When Anne shares with a friend that, “It has all become too much to bear”, her friend suggests that physical therapy would be a great way to become stronger. Anne welcomes the opportunity to meet her mobility goals while building social connection through routine therapist visits and is able to maintain her appointment schedule with the help of a commuter assistance service. Anne's is a classic example of assumptions made in the case of frailty in which an older person's values are overlooked and palliative care, if strategically integrated, could contribute to more meaningful longevity—as defined by the patient. Globally, people are living longer than ever before. The number of adults worldwide aged 65 years or older will double by 2050, totalling about 1·6 billion or 16% of the global population.1United Nations Department of Economic and Social AffairsLeaving no one behind in an ageing world: World Social Report 2023.https://www.un.org/development/desa/dspd/world-social-report/2023-2.htmlDate: 2023Date accessed: June 28, 2023Google Scholar With advanced ageing, comes increased risk for multimorbidity, which exacerbates the need for palliative care. Roughly 40% of the 61 million people in need of palliative care worldwide are aged 70 years or older.2Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (631) Google Scholar Frailty is an often age-associated syndrome of vulnerability and decreased function that endangers physical independence and cognitive wellbeing while negatively affecting outcomes and increasing disability risk.3Tang KF Teh P-L Lee SWH Cognitive frailty and functional disability among community-dwelling older adults: a systematic review.Innov Aging. 2023; 7igad005Crossref PubMed Scopus (2) Google Scholar System-level gaps leave frail older adults without accessible palliative care services (eg, no in-home services for patients who are homebound). Many medical interventions for patients with frailty and comorbidities, from chemotherapy to surgeries, can instigate devastating sequelae. Thresholds to identify frail older adults are lacking globally, but especially in low-income and middle-income countries.4Farooqi M Papaioannou A Bangdiwala S Rangarajan S Leong D How regional versus global thresholds for physical activity and grip strength influence physical frailty prevalence and mortality estimates in PURE: a prospective multinational cohort study of community-dwelling adults.BMJ Open. 2023; 13e066848Crossref Scopus (0) Google Scholar The worldwide prevalence of frailty is unclear, with significant variation in community-dwelling estimates and as high as 60% in some patients concurrently having mild cognitive impairment.5Bellelli G Zucchelli A Benussi A et al.Assessing frailty at the centers for dementia and cognitive decline in Italy: potential implications for improving care of older people living with dementia.Neurol Sci. 2023; 44: 3509-3514Crossref PubMed Scopus (1) Google Scholar Palliative care integration can bolster patient satisfaction in geriatric populations,6Schelin MEC Fürst CJ Rasmussen BH Hedman C Increased patient satisfaction by integration of palliative care into geriatrics—a prospective cohort study.PLoS One. 2023; 18e0287550Crossref PubMed Scopus (0) Google Scholar but little is known about the broader palliative care needs of frail older adults. Frailty is insidious, leading to prolonged dwindling of health and wellbeing, accompanied by an unclear clinical trajectory near end of life. Research is insufficient on the proportion of frail older adults needing palliative care, mechanisms to best deliver services to this population, and the ideal care models for both generalist palliative care (ie, delivered at the primary level) and specialist palliative care (ie, multiprofessional teams with specialty palliative care qualifications).7Radbruch L De Lima L Knaul F et al.Redefining palliative care-a new consensus-based definition.J Pain Symptom Manage. 2020; 60: 754-764Summary Full Text Full Text PDF PubMed Scopus (316) Google Scholar Specialist palliative care can assist with managing complex symptom burdens and psychological, spiritual, or existential crises, while also equipping other health team members with primary palliative care skills.7Radbruch L De Lima L Knaul F et al.Redefining palliative care-a new consensus-based definition.J Pain Symptom Manage. 2020; 60: 754-764Summary Full Text Full Text PDF PubMed Scopus (316) Google Scholar Generalist palliative care training for all health professionals becomes increasingly important in low-income and middle-income countries where specialist palliative care is often unavailable.2Knaul FM Farmer PE Krakauer EL et al.Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report.Lancet. 2018; 391: 1391-1454Summary Full Text Full Text PDF PubMed Scopus (631) Google Scholar Frailty might not always be a condition to be battled or overcome; in fact, throughout its various stages, frailty might offer opportunities for self-development that palliative care clinicians can support. Poor mobility and decreased community engagement might invite deep reflection, meaning-making, and generativity (ie, legacy building).8Bjerkmo L Helgesen AK Blix BH Being and becoming ‘a frail older adult’: meaning-making and resistance through storytelling.J Aging Stud. 2023; 65101128Crossref PubMed Scopus (0) Google Scholar This space can afford frail older adults with much needed time to achieve significant milestones (eg, forgiveness, closure, connecting with creativity) and discover new aspects of self-efficacy and self-reliance. The intelligent integration of palliative care can provide aid beyond symptom management, assisting all frail older adults to redefine their goals and optimise how their time is spent in alignment with their health-related values. Primary teams can provide palliative care across the stages of frailty and, as needed, in consultation with specialists for refractory and complex needs (panel). Since most frail adults also have cognitive decline or dementia,3Tang KF Teh P-L Lee SWH Cognitive frailty and functional disability among community-dwelling older adults: a systematic review.Innov Aging. 2023; 7igad005Crossref PubMed Scopus (2) Google Scholar pragmatic steps for all clinicians include initiating a generalist palliative care approach starting at diagnosis of frailty; consulting specialist palliative care at the onset of dementia for patients with frailty to effectively anticipate end-of-life needs; and implementing systematic prognostication of survival, starting at frailty or dementia diagnosis. True, there is little evidence on frailty trajectories preceding end of life, which complicates both prognostication and care planning. However, multicountry data suggest a linear progression of frailty in the years before death with higher frailty rates and an increased rate of frailty related changes associated with dementia and older age.10Jenkins ND Welstead M Stirland L et al.Frailty trajectories and associated factors in the years prior to death: evidence from 14 countries in the Survey of Health, Aging and Retirement in Europe.BMC Geriatr. 2023; 23: 49Crossref PubMed Scopus (1) Google Scholar Knowledge of these trajectories can guide effective and timely palliative care integration to enhance relationships between patients, caregivers, and clinicians while promoting tailored patient-centred and family-centred support and more intentionally relieving health-related suffering. These are the initial steps forward for the frail older adult—for people like Anne—sojourning with them to co-create what meaningful longevity could be.PanelPrioritising palliative care for frail older persons throughout the illness trajectoryLiving with mild frailty* •More evident slowing; needs help in higher-order instrumental activities of daily living•Probably impairs shopping, walking outside alone, meal preparation, and housekeepingGeneralist and specialist palliative care priorities •Identify safety issues and available home nursing and assistance services•Discuss values and goals of care with patients and caregivers•Assess baseline physical and psychological function, and spiritual and social wellbeing•Review advance directives, including health care proxy or surrogate decision-maker•Address symptom management related to multimorbidity•Counsel on social security and social support services (if available)Living with moderate frailty* •Needs help with all outside activities and housekeeping•Often has problems with stairs, needs help bathing, and possible assistance dressingGeneralist and specialist palliative care priorities, as above, plus •Perform in-depth symptom assessment and design a treatment plan for pain and other distressing symptoms (eg, dyspnoea)•Revisit goals, values, and advance directives•Facilitate family meeting to resolve ethical or legal concerns•Promote goal-concordant care and facilitate iterative advance care planning•Ensure additional psychosocial and educational resources for patient and caregivers•Engage palliative social worker to assess living situationLiving with severe frailty* •Completely dependent for cognitive and physical personal care•Seems stable and not at high risk of dying within next 6 monthsGeneralist and specialist palliative care priorities, as above, plus •Support generativity and legacy development•Assess for caregiver distress and needs•Ensure personhood remains central to medical decision making•Promote transparency in serious illness conversations, while balancing hope and realismLiving with very severe frailty* •Completely dependent for personal care•Approaching end of life•Probably could not recover from even minor illnessesGeneralist and specialist palliative care priorities,as above, plus •Educate about hospice or specialised services and assist with procuring access•Help develop mitigation plan for minor illness and injury (eg, home care vs hospital admission)•Ensure timely and adequate pain and symptom management, including access to essential palliative care medicines (eg, opioids for moderate to severe pain and terminal dyspnoea)•Deliver end-of-life care aligned with patient and surrogate goals and values;•Provide person-centred and culturally sensitive psychosocial and spiritual interventions•Offer anticipatory bereavement support for caregivers*Clinical Frailty Scale Definition (adapted).9Rockwood K Theou O Using the Clinical Frailty Scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar Living with mild frailty* •More evident slowing; needs help in higher-order instrumental activities of daily living•Probably impairs shopping, walking outside alone, meal preparation, and housekeeping Generalist and specialist palliative care priorities •Identify safety issues and available home nursing and assistance services•Discuss values and goals of care with patients and caregivers•Assess baseline physical and psychological function, and spiritual and social wellbeing•Review advance directives, including health care proxy or surrogate decision-maker•Address symptom management related to multimorbidity•Counsel on social security and social support services (if available) Living with moderate frailty* •Needs help with all outside activities and housekeeping•Often has problems with stairs, needs help bathing, and possible assistance dressing Generalist and specialist palliative care priorities, as above, plus •Perform in-depth symptom assessment and design a treatment plan for pain and other distressing symptoms (eg, dyspnoea)•Revisit goals, values, and advance directives•Facilitate family meeting to resolve ethical or legal concerns•Promote goal-concordant care and facilitate iterative advance care planning•Ensure additional psychosocial and educational resources for patient and caregivers•Engage palliative social worker to assess living situation Living with severe frailty* •Completely dependent for cognitive and physical personal care•Seems stable and not at high risk of dying within next 6 months Generalist and specialist palliative care priorities, as above, plus •Support generativity and legacy development•Assess for caregiver distress and needs•Ensure personhood remains central to medical decision making•Promote transparency in serious illness conversations, while balancing hope and realism Living with very severe frailty* •Completely dependent for personal care•Approaching end of life•Probably could not recover from even minor illnesses Generalist and specialist palliative care priorities,as above, plus •Educate about hospice or specialised services and assist with procuring access•Help develop mitigation plan for minor illness and injury (eg, home care vs hospital admission)•Ensure timely and adequate pain and symptom management, including access to essential palliative care medicines (eg, opioids for moderate to severe pain and terminal dyspnoea)•Deliver end-of-life care aligned with patient and surrogate goals and values;•Provide person-centred and culturally sensitive psychosocial and spiritual interventions•Offer anticipatory bereavement support for caregivers *Clinical Frailty Scale Definition (adapted).9Rockwood K Theou O Using the Clinical Frailty Scale in allocating scarce health care resources.Can Geriatr J. 2020; 23: 210-215Crossref PubMed Google Scholar There was no funding source involved in the writing of this manuscript. We declare no competing interests.